A r c h i v e d  I n f o r m a t i o n

ANNUAL REPORT OF CHILDREN IN STATE AGENCY INSTITUTIONS FOR NEGLECTED OR
DELINQUENT CHILDREN, ADULT CORRECTIONAL INSTITUTIONS, AND
COMMUNITY DAY PROGRAMS FOR NEGLECTED OR DELINQUENT CHILDREN

PART I - INSTITUTION AND STATE AGENCY

1. Name and address of institution, community day program, or adult correctional institution 2. Name and address of State agency

PART II - BASIS FOR ELIGIBILITY

YES NO
  1. Is a regular program of instruction provided for the children in the institution or community day school?

  2. Is the State agency responsible for providing free public education for the children in the institution or community day program?

  3. Is the average length of stay in the institution or community day program at least 30 days?

IF ANSWER TO ALL THREE QUESTIONS ABOVE IS YES, PROCEED TO PART III.








PART III - TYPE OF INSTITUTION AND ENROLLMENT

CATEGORY
(Check one)		 NUMBER OF CHILDREN UNDER 21 ENROLLED IN A REGULAR PROGRAM OF INSTRUCTION SUPPORTED BY STATE FUNDS FOR AT LEAST
20 hours
per week		 15 hours
per week
[  ] INSTITUTION FOR NEGLECTED CHILDREN
A public or private residential facility, other than a foster home, that is operated primarily for the care of children who have been committed to the institution or voluntarily placed in the institution under applicable State law, due to abandonment, neglect, or death of their parents or guardians.


[  ] INSTITUTION FOR DELINQUENT CHILDREN AND YOUTH
A public or private residential facility that is operated primarily for the care of children who have been adjudicated to be delinquent or in need of supervision.


[  ] COMMUNITY DAY PROGRAM
A regular program of instruction provided by a State agency at a community day school operated specifically for neglected or delinquent children.


[  ] ADULT CORRECTIONAL INSTITUTION
A facility in which persons are confined as a result of a conviction for a a criminal offense, including persons under 21 years of age.



PART IV - ADJUSTED ENROLLMENT TO REFLECT THE RELATIVE LENGTH OF THE STATE AGENCY'S ANNUAL PROGRAM

Enrollment
(from Part III)		 No. of Days
Per Year
Educational
Program Operates		 Adjusted
Enrollment

X

DIVIDED
BY		 180 =


PART V - CERTIFICATION

I certify that the information provided meets the requirements of Title I, Part D, Subpart 1 and is, to the best of my knowledge, complete and accurate.

___________________________________________
(Typed name of institution official)

___________________________________________
(Signature and date)

___________________________________________
(Typed name of State agency official)

___________________________________________
(Signature and date)

This page last modified November 11, 1998 [gkp]

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